A lightly edited transcript of the Google Hangout is below, along with additional references for works cited during the talk. Also, La Puma lists several specific foods that have some evidence supporting their potential effects in hypertension.

John La Puma, MD: Welcome to CulinaryRx from MedPage Today. Today we'll try to help a patient with glucose intolerance, sometimes known as prediabetes. Here is the case which is also posted on MedPageToday.com/Blogs/CulinaryRx.

A 41-year-old second-generation Asian-Indian man presents for a routine visit; he has no first-degree relatives with type 2 diabetes. He works at a desk in front of a computer most of the day getting up every couple of hours by iPhone alert and eats at least one meal per day sitting there. Often that's cereal in the morning or rice and lentils at night and fast food during the day.

He eats a few traditional Indian foods – opo, mango lassi, saag paneer – when his mom makes them for him. And he's planted a garden with Indian herbs both for flavor and for medicine: holy basil, dill, cumin, coriander, and mustard. He does not drink alcohol, nor does he smoke. He exercises by riding a stationary bike 20 to 30 minutes, twice weekly. He does not own a dog or another pet.

Today in the office his body mass index is 24 kg/m2. And his blood pressure is 129/84. His physical exam is within normal limits except for a waist circumference of 37 inches. His height is 68 inches. His fasting plasma glucose is a 103 mg/dL. And his glycated hemoglobin is 6.8%, triglycerides are 120 mg/dL.

We had 11 comments at last look on MedPage Today on this case. And our commenters are both clinicians and nonclinicians. They suggest things like adding protein to every meal, tracking food intake, and adhering to an ovo-lacto vegetarian pattern.

Today we have Dr. Dan Nadeau, the program director of the Mary & Dick Allen Diabetes Center at the Hoag Medical Center in Newport Beach. And Dr. David Jenkins, a professor in Canada, at the University of Toronto, of Nutrition and Metabolism and the director of Risk Factor Modification Center in St. Michael's Hospital in Toronto.

Welcome to you both, you're both terrific experts in diabetes management so I wanted to jump right in and ask Doctor Nadeau, what should this patient eat and what should this patient avoid eating, without going into too much detail about the actual diabetes here.

Daniel Nadeau, MD: Right. Well, I think a few things that he might do is to move to whole grains. For example, the rice that he chooses might be a long grain brown rice like brown basmati rice for example. Long grain rice is digested much more slowly than short grain rice. That would be one simple change.

One thing that I also recognize in people with diabetes is they tend to have a lot of inflammation going on in their body, and that brightly colored fruits and vegetables are good for them. So I actually – it's funny but I recommend that people do blueberry smoothies for breakfast. So that would include hopefully wild blueberries, maybe unsweetened vanilla, soy or almond milk with some protein powder, usually a P-based protein powder. And that starts their day quite well. Very few complaints of high blood sugars. With that type of approach something that they enjoy and something that really improves their glucose control and also I think it helps potentially to reduce their inflammation as well.

La Puma: Good approach for breakfast. That sounds like a vegetarian eating plan consistent with his background. Doctor Jenkins, you studied this previously as well. How would you approach an eating plan for this patient?

David Jenkins, MD: Well I think I'd endorse what Dan's saying which I think is excellent.

And I would probably add that I think that pushing him further along with his traditional diet would be helpful. I think that eating chick peas, lentils, beans, these sort of things are very good sources of carbohydrates. I certainly endorse those. I know that when I'd been to Bombay, now called Mumbai, but it was called Bombay, I was always thrilled to be at festive times when people had a lot of sort of almond type cookies and sweets, desserts. So eating that I think is good. I think possibly for him it may be another way of reducing the glycemic load by introducing some nuts into his desserts. I think the breakfast that Dan has put forward could have almonds on it, too, along with the blueberries, along with the soy smoothie. And the extra vegetables, protein one can get in rice proteins, too in concentrated form which impacts – which can be very good sprinkled on these sort of things. Increase the proteins, perhaps increasing the good oils in his diet would be useful.

La Puma: And in fact both of you suggested proteins and carbohydrates at breakfast for the blueberries and the protein powder leaving out the good oils which are important both for absorption of specific vital nutrients to reduce inflammation as Dan indicates as well as to improve satiety and of course to not release insulin. Having fat in the diet – fat is really the only noninsulin-releasing macronutrient.

So what kind of role does fat have for this patient with arguably glucose intolerance and maybe prediabetes or early diabetes? More fat or less fat?

Jenkins: I think that if one's talking about a plant-based diet and I think it's in that context then I think it would be logical to have our fat discussion on. We're not talking about more butter, more lard, more beef fat, we're not talking about these things. We're talking about the oils, we're talking about things like olive oil, canola oil which we've also studied and works very well in the same way and other rich mono unsaturated vegetable oil fat sources. And this seems to do very well in terms of reducing the glycemic load and improving as you've just been discussing, improving overall glycemic control.

So again as I say, provided we're talking about plant-based things, the canolas, the olives and these sorts of oils, then I think we're talking in a sensible way about how to reduce the glycemic impact of the overall diet.

But again I would also encourage the use of these low glycemic index foods. And I would have added also in terms of the rice story which I think is an important one that Dan alluded to. We've found that using barley which has the beta glucan which can lower cholesterol and is a low glycemic index cereal food, that, too is useful.

So many people can find that they can use barley in many of the same ways that they can use rice. I agree more on the Chinese domain because they like sticky things that you can pick up with chopsticks. In this case traditionally one uses one's hands to pick up the Indian food. But I think what we're saying is that these sorts of new carbohydrate – or different carbohydrate forms are very useful.

La Puma: Dr. Nadeau, is it correct that the dietary carbohydrate restriction really has the greatest effect on decreasing blood glucose levels?

Nadeau: I try to emphasize – I don't believe that there is a specific diet for people with diabetes. I think there is one healthy diet that we should all try to achieve. And that diet includes whole grains, vegetables, fruits, beans, legumes and other healthy proteins such as nuts. And if you are going to eat meat, it should be more fish, turkey and chicken as opposed to the red meat I think.

And so in terms of carbohydrates I think it's really the kind of carbohydrate you have in – I always try to emphasize to people that if they're eating whole grains, they're going to do just fine.

I'd be curious to know what Dr. Jenkins thinks of that European block bread where you can see the grain in it already. I'm almost convinced that you really don't absorb anything from that bread when you eat it. That it kind of goes right through you basically without glucose very much.

Jenkins: Pumpernickel bread; the bread that if you drop them, they will break your feet. And it had to be cut for you. You couldn't possibly cut it yourself without a saw. You're quite correct. Those breads traditionally we've used these for a low glycemic index bread generally and worked very well in this particular department. And also it caused you as you say to have to do a lot of chewing in order to get the things absorbed.

There is one small problem and that is that it has become very fashionable among the makers of pumpernickel bread to make it more palatable to the diet by adding glucose syrup or beet sugar syrup. So be wary. Some of the things we thought were excellent in their traditional form now look still traditional but are more palatable and unfortunately higher glycemic index. So you're right, those sort of things have been tremendous, but we're now having to be very cautious about their use.

La Puma: Two final questions. One, I'm so trying to understand whether dietary carbohydrate restriction has the greatest effect on decreasing glucose levels. From the discussion which has been primarily about foods rich in carbohydrates, I'm getting the feeling that they ought not to be restricted more than let's say 60 grams a meal which is what I think you shoot for if you put a number on it. First of all, is that correct? Ought carbohydrates be restricted because they have the greatest effect on decreasing blood sugar levels?

Nadeau: Well, let's have Doctor Jenkins comment on that since I already kind of chimed in.

Jenkins: I'll chime in on that. As I said, I made the point at the beginning, I'm all for plant food components. So if you want to get your fat from nuts, if you want to get it from avocado, you want to get it from canola, you want to get it from olive – I do believe that these things may for many people, not for all but for many people be useful and we've found them useful in our diabetic diets in terms of obtaining compliance. Because I would like people to eat low glycemic index foods, the sort of things that Dan's been talking about. That's what I would like. But I find that for many people they need the mouth feel, perhaps the taste of fat. And so let's use the good fats which also keep the cholesterol in its place rather than the bad fats or the higher glycemic index foods.

So my worry is it's a tremendous thing if you can use these fats to displace the other fluffy pleasant carbohydrate foods that melt in your mouth that we all like so much. At least if you've got something fatty that also melts in your mouth. And I think we have to understand that human beings like particular foods and like particular mouth feels.

La Puma: Exactly. So is that 10% of calories, 20% – 30, 40, 50, 60 to have plant-based, including to consume coconut oil fats that add both mouth feel, satiety and really let's say pleasure to eating. Is that the majority of calories that this man should eat?

Jenkins: We're doing a study now in diabetics and I can give you the results probably in 2 years' time looking at the effects of high fat, high protein plant-based diets. And we're looking in terms of how well they do in glycemic control versus what we would call the healthy diet which is the high cereal fiber, high grain, low fat dairy type approach to diet which would fit this Indian gentleman also very well both in terms of philosophy and in terms of nutrition.

I haven't got the read out for you in diabetes at present but we can say that in patients who are hyperlipidemic, a period of high plant oil and high plant protein diet does very well for them. Certainly in getting acute weight loss. It's not a diet which is necessarily maintained over the long term, this is true. So the remaining 6 months as it were in the study, many people went back to higher carbohydrate diets but still keeping some components of the vegetable oil and vegetable protein increase in their diet. With that we've seen improvements, even long term. Not as dramatic as you see when you provide it metabolically in the first one month but certainly following over in the further 6 months we still get the residual effect of this sort of diet and it seems to be sustainable.

La Puma: And is that a ketogenic diet?

Jenkins: No, absolutely not. So we're above the level of ketosis. So we're not truly Atkins, we're what I would call eco-Atkins.

Nadeau: So that might include more tofu for example.

Jenkins: Absolutely, yes.

Nadeau: Perfect. I mean I think the big thing is what kills most people with diabetes is heart disease. So if you move toward a plant-based diet, you can end up when you're 60 years old having a calcium score of 0. You'll not achieve that if you're on a diet that includes regular consumption of beef and cheese and ice cream and other [junk] foods.

So I think recognizing that connection between diabetes and heart disease and what really kills these people – one needs to I think keep in mind that the healthiest foods for the heart are those that are plant-based. And if we can push our patients to move more toward a diet that includes fruits, vegetables, whole grains and really start to think it's okay to have a meal where there are salads and chick peas and plenty of turmeric in it with brown rice and fresh vegetables. It's an ideal meal for people.

And to this gentleman I would say "go back to your roots, go back to your roots where they were really eating whole grains and legumes and away from this Americanized approach to eating." And you can rejoice in that and have a delicious diet that really – and you know I've heard in India there is virtually no Alzheimer's. And part of that is because they have a lot of turmeric in their diet. It seems to be highly protective of the brain actually.

So this man can go back to his roots and really have a very fulfilling diet.

Jenkins: I would like to just endorse what Dan said and also put one of the things that I think is there to his heart: if we send this gentleman back to his roots, he will also take more physical activity. And I think that's very important, too. So this sort of a diet with a greatly increased level of physical activity would do him extremely well. Especially at his phase and at his time of life.

La Puma: Well, very good. We've had a really nice discussion, thank you both for exploring the corners of the plant kingdom especially and of including all the macronutrients. We found in our practice as I think Dr. Jenkins alluded to early on, I think Dr. Nadeau mentioned it as well that peanuts of any kind would be a great snack for a diabetic and I actually have people put 20-30 almonds or 20 hazelnuts or 13 walnuts in little plastic bags in their glove compartments, or in their desk drawers or their backpack or their duffer bag, so that they would always have a good snack with them. And they post them in different parts of their life so it's easy and convenient for them instead of grabbing a bag of Cheetos or something like it.

So we have several different approaches to these eating plans for diabetes and prescriptions for our patient with prediabetes. For more information, please read our transcript and the references on Foods for Glucose Intolerance and Diabetes Prevention at MedPageToday.com/Blogs/CulinaryRx.

I want to thank my guests, Dr. Dan Nadeau in Long Beach and Dr. David Jenkins in Toronto. Please comment on this discussion and share it with your friends and colleagues. Thanks so much for listening, and thanks to our guests for joining us.

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